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Journal of Bodywork and Movement Therapies (2004) 8, 278285

Bodywork and

Journal of

Movement Therapies

SELF-HELP: CLINICIAN SECTION

Spinal stabilizationan update. Part 3training$

Craig Liebenson, DC

10474 Santa Monica Blvd., # No. 202, Los Angeles, CA 90025, USA

Introduction

Reactivating spine pain patients is a key to earlyrecovery from acute and subacute episodes (Mal-mivaara et al., 1995; Indahl et al., 1998), preven-tion of recurrences (Hides et al., 2001), andtreatment of chronic pain, disability, and failedsurgery syndrome (Fordyce et al., 1986; Lindstromet al., 1992; Manniche et al., 1991; Osullivan etal., 1997; Timm, 1994). The first part of this seriesdescribed the role of instability in low backproblems (LBP) as well as specific types ofbiomechanical advice to prevent low back irrita-tion. The second part described an assessment ofthe stability system. This third and final part willdescribe a step-wise approach to patient reactiva-tion from simple introductory exercises with widemargins of safety/stability to advanced functionalperformance training with much smaller margins ofsafety/stability.

Safe back principles have emerged from rigorousanalysis of biomechanical and kinesiological as-pects of spinal function (McGill, 2001; Liebenson,1999). The goals shared with the patient are to

offer palliative care, spare the spine (see part one),and then to stabilize the spine. Spine stabilitytraining includes 3 distinct levels of care. First,introductory exercises to find a patients functionalrange should be given. Second, low-load endurance

training of stability patterns is emphasized (Hideset al., 1996; Timm, 1994; Osullivan et al., 1997).Third, such stability patterns should be trained infunctional activities to enhance performance dur-ing activities of daily living (ADLs), sport or workdemands.

Sport psychology and behavioralmedicine

Behavioral medicine or sports psychology tenets ofpaced activity and the relationship between hurtand harm should be discussed with the patient.Many low back pain (LBP) patients have excessivefear avoidance beliefs or catastrophizing behaviorswhich promote a passive, symptom-driven ap-proach, excessive pathoanatomic diagnositic test-ing, and a poor prognosis (Linton, 2002). At theother end of the spectrum are individuals who areoverly aggressive which can lead to a boom orbust mentality.

The middle path is best exhibited by the modern

emphasis on quota-based graded exposures tofeared stimuli (Linton, 2002). This operant condi-tioning model successively demonstrates to patientsthat hurt does not necessarily equal harm, andthat activitycontrary to the patients beliefsisactually beneficial. The activities chosen shouldbe mutually agreed upon and at most have onlyslight mechanical sensitivity (MS). The exercisesshould be designed to improve the abnormal motor

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www.intl.elsevierhealth.com/journals/jbmt

1360-8592/$ - see front matterr 2004 Published by Elsevier Ltd.doi:10.1016/j.jbmt.2004.06.002

$This paper may be photocopied for educational use.Tel.: +1-310-470-2909; fax: +1-310-470-3286.

E-mail address: [email protected] (C. Liebenson).
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control (AMC) identified in the evaluation (see Parttwo). Regular re-evaluation of activity intolerances(AI), MS, and AMC is necessary to prove to thepatients that their fear is unfounded.

Training

Prior to initiating low back exercise trainingbiomechanical advice about how to avoid low backirritation during ADLsspine sparing strategies-should be taught (see Part one).

A step-wise approach to reducing activity intol-erances and restoring function has been developed.Once advice has been given about how to spare thespine during ADLs, and the safety exercise dis-cussed, then a progressive approach beginning withexercises with a wide stability/safety margin areprescribed to quota. The goal is to improve motor

control by emphasizing coordination during simplemovements designed to stabilize the back (i.e. hiphinging). Such introductory exercises are thenprogressed by adding low-load endurance chal-lenges. Finally, exercises are progressed to includefunctional or performance components which mimicas closely as possible the actual ADL, work or sportsdemands that the individual faces (see Table 1)

Introductory traininggraded exposures togrooved stability patterns

In level one training postural control, musclebalance and pain reduction or centralization isthe focus. The goal is to groove motor patternswith safe, low-load activities. This requires anemphasis on the cognitive-kinesthetic awarenessstage of motor control (Shumway-Cook and Woolla-cott, 1995). Most patients have poor kinestheticawareness of how to produce and/or control motionof their problem area. The patient learns to dis-cover how to move and centrate an importantregion such as the lumbo-pelvic, scapulo-thoracic,or cervico-cranial. They acquire the skill to performthe movement and then to limit it to a pain-less

or pain centralizing functional range.When a patient has a lot of MS with normal

ranges of motion, especially if there is referred or

radicular pain, the McKenzie approach of prescrib-ing movements which centralizes referred pain andavoiding movements which peripheralize the symp-toms is strongly recommended. In disc patientsthese movements often involve end-range positionssuch as extension. The key is to regularly recheckthe patients MS to confirm that the patients overall

functional range is expanding.Behavioral principles/sport psychology are es-

sential to exercise training. It is important toinitiate exercise training with exercises that havea large safety/stability margin. Such exercisesshould be mutually agreed upon with the patient.They should be carried out to a quota even if mildlyuncomfortable. In chronic pain patients the ex-pectancy of re-injury is typically based on anactivity avoidance belief or catastrophizing ten-dency and not an actual experience (Crombez etal., 1998). Graded exposures to feared stimuli are

an excellent way to operantly condition painpatients, and thus prevent deconditioning andinitiate functional reactivation. Pacing is importantwith any exercise prescription so that both toolittle or too much activity is avoided (Harding andde Williams, 1995; Harding et al., 1998; Butler andMoseley, 2003).

Exercises prescribed should be those with widemargins of safety/stability. Generally, loads under3000 N of force are considered safe for acute/subacute exercise training. Routine ADLs involveabout 2000 N and the NIOSH limit for repetitivetasks is 3300 N (see Part one). Table 3 shows the load

profiles for a variety of low back exercises. Theyshould be performed after limbering up and notimmediately upon arising or after prolonged sitting(Snook et al., 1998; Green et al., 2002; Wilder etal., 1996). Good form or coordination is a pre-requisite for such training (Osullivan et al., 1997).Finally, trunk muscle co-activation (e.g. abdominalbracing) is recommended to increase the stabilitymargin (Cholewicki and McGill, 1996; McGill, 2002;Granata and Marras, 2000; Stokes et al., 2000).

The catcamel is an ideal way to warm-up thespine. It is not a stretch and teaches the coordina-

tion to move and position the spine through an arcof motion. 810 repetitions of gentle limberingwithout stretching is appropriate.

Limberingcatcamel (see Fig. 1).

The quadruped leg reach teaches neutralspine control during distal extremity motions. Thekey is avoiding spinal torsion or lumbar hyperexten-sion. 810 slow repetitions with brief isometricholds is the goal.

Quadruped leg reach (see Fig. 2).

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Table 1 Stability training progressions.

1. Introductory traininggraded exposures togrooved stability patterns

2. Isolation of specific stability patterns3. Functional integrated training

Spinal stabilizationan update. Part 3training 279


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Abdominal bracing involves co-activation ofmuscles in 3601 around the lumbar spine. It is alight contraction 510% of MVC similar to beingtickled or bearing down slightly (McGill, 2002;McGill et al., 2003). However, the key is that thebreath is not held during the brace, nor isabdominal contraction entrained to a certain phase

of respiration. If a patient holds the quadrupedposition and the clinician attempts to gently pushthe torso to and fro bracing will automatically befacilitated. The same can be done in other positionsor exercises such as the dead bug or side bridge.

Often mobility of surrounding regions is re-stricted thus increasing load on the spine. Oneexample, would be reduced mobility in the mid-thoracic, hip, knee and ankle during a squat orlunge resulting in poor maintenance of lumbarlordosis and thus disc overload. In such casesflexibility training such as of the mid-thoracic or

hip flexors will help to spare the spine

T48 stretch (see Fig. 3). Psoas stretch (see Fig. 4).

Once the patient learns to move and position theirspine in fundamental ways then a progression tomore complex exercises and functional activities canoccur. There are always two aspects to the decisionof whether or not a patient is ready to progress ornot. The first is concerned with MS and the secondwith AMC. The sooner in the program actual

functional activities are trained the better but, itis necessary at each step that (a) mechanicalsensitivity is not increased, and (b) that motorcontrol is re-educated. MC involves functionalcentration or neutral posture of key joints, normalrespiration (i.e. no breath holding), and avoidance ofabnormal patterns of muscle substitution (Richard-son et al., 1999). If for instance, an exerciseincreases MS by either peripheralizing symptoms orincreasing painful ROMs on post-exercise auditing

then the correct introductory training has not beenachieved. Similarly, even if mechanical sensitivity isdecreasing but the patient is not learning how toperform simple movement patterns with good formthey are not ready to progress.

Isolation of specific stability patterns

The goal of the second level of stability training isto build endurance into the new spine sparingmotion patterns. This requires that the intensity of

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Figure 2. Quadruped leg reach.

Figure 3. Foam roll.

Figure 4. Standing hip flexor stretch.

Figure 1. (a, b) Catcamel.

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can easily perform a sets of 1012 slow repetitionswith good form they are ready to move on. Forexample,

Move on:

Quadruped opposite leg/arm reach with neu-tral spine control.

Dont move on:

Quadruped opposite arm/leg reach with lumbo-

sacral hyperextension or trunk rotation.

Integrationfunctional integrated training(FIT)

Functional stability training is goal oriented. Non-functional positions such as recumbent may be usedas stepping stones to isolate and groove stabilitypatterns. However, as soon as possible corestability must be trained in exercises mimicking the

demands the patients face in their home, occupa-tional, and recreational activities.

The sooner in the program actual functionalactivities are trained the better. But, it is necessaryat each step that the movement is in the patients

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Figure 6. Side bridge on knees (a) start position (b) finalposition.

Figure 7. Trunk curl-up.

Figure 8. Dead bug supported (a) start position (b) finalposition.

Figure 5. Quadruped opposite arm+leg reach.

Figure 9. Dead bug unsupported (a) start position (b)final position.

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functional rangereducing mechanical sensitivityand abnormal motor control while being as func-tional as possible.

Unless, functional training occurs there is noguarantee that the individual will be stable duringreal world challenges. Examples of functionaltraining include squats, lunges, pushing, pulling,

catching, carrying, etc. For more fit individuals andto enhance performance or prevent injury indemanding sports or occupations stability patternsmay be further challenged by the addition ofunstable surfaces such as balance boards andgymnastic balls. This provides enhanced propriocep-tive stimulation which facilitates motor learning.

A patients functional range should be identi-fied for each functional training exercise. Forinstance, to train for lifting, rising from a chair,throwing, pushing, or pulling activities squattingshould be analyzed and trained. Typical findings of

dysfunction with squats are poor control of thelower quarter (medial collapseknee valgosity,subtalar hyperpronation, Trendelenberg hip posi-tion or patello-femoral shear) or lumbo-pelvic(stooping substituting for squatting) regions.

A simple squat exercise is the squat with back tothe wall which automatically facilitates hip hinging.

Squat with back to wall (see Fig. 10).

Troubleshooting for medial collapse can includesingle leg stance balance exercises.

Balance reaches (see Fig. 11).

Functional stability during activities such aswalking, climbing or descending stairs, rising fromthe floor, kneeling, throwing, pushing, or pullingcan be re-educated with an exercise such as thelunge. A typical dysfunction or faulty movementpattern with forward lunging is excessive hip andtrunk flexion. A simple exercise that is usuallywithin the patients functional range is toperform a forward lunge while raising the armsoverhead. This will usually re-educate neutrallumbo-pelvic posture automatically.

Forward lunge with arms overhead (see Fig. 12).

If the forward lunge occurs with subtalar hyper-pronation and excellent way to attack success isto attempt an angle lunge with an arm reach (seeFig. 12), this will typically drive the foot intosupination automatically! Whatever is the mostchallenging functional activity the patient canperform with appropriate stability should be theone selected for exercise.

Angle lunge with an arm reach (see Fig. 13).

Common movements such as pushing and pulling

require the patient to make simple multi-planarweight transfers. Pushing is part of functionalactivities such as a tennis forehand, throwing,boxing punch, pushing a shopping cart or vacuumcleaner. Pulling is part of functional activities suchas a tennis backhand, golf swing, throwing afrisbee, lifting a grocery bag out of a car or a babyout of a crib. Pushing and pulling can be trainedwith simple pulley or exercise tubing exercises.

Core twistpush (see Fig. 14). Pull (see Fig. 15).

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Figure 10. Squat with back to wall.

Figure 11. Balance reaches.



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Reactivation progressions should continue untilthe patients functional range includes their

home, sports, occupational demands. Athletes willrequire high-level performance training which willalso include strength/power, agility, and speedchallenges. These would be superimposed on the3 levels of training already described. A frequenttraining error in programs designed for highly fitindividuals is the performance of trunk or spineexercises with high-level strength or agility de-mands, without proper motor control. A step-wiseapproach built upon a foundation of consciouskinesthetic awareness of appropriate motor controlis the best guarantee of injury prevention when

performing high-level activities with a narrowsafety/stability margin.

Conclusion

Safe back training in the acute stage should reducefear of movement, reduce or centralize thepatients pain, and groove appropriate move-ment patterns for basic ADLs. In the subacuterecovery stage training should build endurance in

progressively more challenging and functionalmovement patterns. Exercise should be prescribedin a goal-oriented manner with the patients activecollaboration. In most instances, a realistic goal isto teach patients better spinal awareness duringADLs to spare their spine, and then to give them afew simple exercises to stabilize their spine.Patients engaged in higher level functional activ-ities or with chronic problems will require morechallenging exercises.

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Figure 13. Angle lunge with an arm reach.Figure 12. Forward lunge with arms overhead.

Figure 14. (a, b) Core twistpush.

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References

Axler, C.T., McGill, S.M., 1997. Low back loads over a variety ofabdominal exercises: searching for the safest abdominalchallenge. Medicine and Science in Sports and Exercise 29,804810.

Butler, D., Moseley, L., 2003. Explain Pain. Noigroup Publica-tions, Adelaide, Australia.

Cholewicki, J., McGill, S.M., 1996. Mechanical stability of the invivo lumbar spine: implications for injury and chronic lowback pain. Clinical Biomechanics 11 (1), 115.

Crombez, G., Vlaeyen, J.W., Heuts, P.H., et al., 1998. Pain-related fear is more disabling than pain itself: evidence onthe role of pain-related fear in chronic back pain disability.Pain 80, 329339.

Fordyce, W.E., Brochway, J.A., Bergman, J.A., et al., 1986.Acute back pain: a control-group comparison of behavioral

vs. traditional management methods. Journal of BehavioralMedicine 9, 127.Granata, K.P., Marras, W.S., 2000. Costbenefit of muscle

cocontraction in protecting against spinal instability. Spine25, 13981404.

Green, J., Grenier, S., McGill, S.M., 2002. Low back stiffness isaltered with warmup and bench rest: Implications forathletes. Medicine and Science in Sports and Exercise 34(7), 10761081.

Harding, V., de Williams, A.C.C., 1995. Extending physiotherapyskills using a psychological approach: cognitive-behaviouralmanagement of chronic pain. Physiotherapy 81, 681687.

Harding, V.R., Simmonds, M.J., Watson, P.J., 1998. Physicaltherapy for chronic pain. PainClinical Updates, Interna-tional Association for the Study of Pain 6, 14.

Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus musclerecovery is not automatic after resolution of acute, first-episode of low back pain. Spine 21 (23), 27632769.

Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long-termeffects of specific stabilizing exercises for first-episode lowback pain. Spine 26, e243e248.

Indahl, A., Haldorsen, E.H., Holm, S., Reikeras, O., Hursin, H.,1998. Five-year follow-up study of a controlled clinical trial

using light mobilization and an informative approach to lowback pain. Spine 23, 26252630.

Liebenson, C.S., 1999. The safe back workout. JNMS 7(1).Lindstrom, A., Ohlund, C., Eek, C., et al., 1992. Activation of

subacute low back patients. Physical Therapy 4, 279293.Linton, S.L. (Ed.), 2002, New Avenues for the Prevention of

Chronic Musculoskeletal Pain and Disability. Elsevier, Am-sterdam.

Malmivaara, A., Hakkinen, U., Aro, T., et al., 1995. Thetreatment of acute low back painbed rest, exercises, orordinary activity?. New England Journal of Medicine 332,351355.

Manniche, C., Lundberg, E., Christensen, I., Bentzen, L.,Hesselesoe, G., et al., 1991. Intensive dynamic backexercises for chronic low back pain. Pain 47, 5363.

McGill, S., 1995. The mechanics of torso flexion: situps andstanding dynamic flexion manouvres. Clinical Biomechanics10, 184192.

McGill, S.M., Juker, D., Kropf, P., 1996. Quantitativeintramuscular myolectric activity of the quadratus lumborumduring a wide variety of tasks. Clinical Biomechanics 11 (3),170172.

McGill, S.M., 1998. Low back exercises: evidence for improving

exercise regimens. Physical Therapy 78 (7), 754

764.McGill, S.M., 2001. Low back stability: from formal

description to issues for performance and rehabilitation.Exercise and Sports Science Reviews 29 (1), 2631(Invited Review).

McGill, S.M., 2002. Low Back Disorders: Evidence basedPrevention and Rehabilitation. Human Kinetics Publishers,Champaign, IL.

McGill, S., Grenier, S., Bluhm, M., Preuss, R., Brown, S., Russell,C., 2003. Previous history of LBP with work loss is related tolingering deficits in biomechanical, physiological, personal,psychosocial and motor control characteristics. Ergonomics46, 731746.

Osullivan, P., Twomey, L., Allison, G., 1997. Evaluation ofspecific stabilizing exercise in the treatment of chronic low

back pain with radiologic diagnosis of spondylolysis orspondylolysthesis. Spine 24, 29592967.

Richardson, C., Jull, G., Hides, J., Hodges, P., 1999. TherapeuticExercise for Spinal Stabilization in Lower Back Pain. ChurchillLivingstone, New York.

Shumway-Cook, A., Woollacott, M., 1995. Motor ControlThe-ory and Practical Applications. Lippincott-Williams & Wilkins,Baltimore.

Snook, S.H., Webster, B.S., McGorry, R.W., Fogleman, M.T.,McCann, K.B., 1998. The reduction of chronic nonspecific lowback pain through the control of early morning lumbarflexion. Spine 23, 26012607.

Stokes, I.A.F., Gardner-Morse, M., Henry, S.M., Badger, G.J.,2000. Decrease in trunk muscular response to perturbationwith preactivation of lumbar spinal musculature. Spine 25,

1957

1964.Timm, K.E., 1994. A randomized-control study of active and

passive treatments for chronic low back pain following L5laminectomy. JOSPT 20, 276286.

Wilder, D.G., Aleksiev, A.R., Magnusson, M.L., Pope, M.H.,Spratt, K.F., Goel, V.K., 1996. Muscular response to suddenload. A tool to evaluate fatigue and rehabilitation. Spine 21,26282639.

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Figure 15. (a, b) Pull.


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